Water Development Commission 6920 YELLOWTAIL ROAD TELEPHONE: (307) CHEYENNE, WY 82002

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1 THE STATE OF WYOMING Water Development Commission 6920 YELLOWTAIL ROAD TELEPHONE: (307) CHEYENNE, WY WATER DEVELOPMENT PROGRAM APPLICATION RURAL DOMESTIC WATER SYSTEMS Funding for projects is based on WWDC recommendations and is appropriated by the legislature from the Water Development Accounts. Legislative authorization is required before the WWDC can begin project work. Applications for projects to the Water Development Program must be submitted no later than March 1. It is helpful if the applications are received prior to the deadline. Applicants seeking Level I reconnaissance studies or Level II feasibility studies for dams and reservoirs need not be an entity of local government. However, applicants for all other Level II feasibility studies and any Level III construction funding must be an entity of local government with taxing and/or assessment authority. Private corporations and individuals are not eligible for assistance. If the applicant is not such a public entity, indicate what steps have been taken to form such an entity in a cover letter for this application. Note: If you are seeking Level III funding for a municipal or rural development project, this is the wrong application. You must complete the application entitled Level III Construction Funding for Municipal/Rural Domestic Projects and provide a feasibility study with detailed cost estimates prepared by a professional engineer registered in Wyoming. APPLICATION REQUIREMENTS The person signing the application must have authority to commit the entity to a binding contract. A notarized copy of a resolution supporting this application passed by the board or other governing body of the entity must be provided. A check for the $1, filing fee must accompany the application. If the application is denied, 75% of the application fee will be refunded to the applicant. A project area map (8.5 x 11 preferred) showing corporate boundaries, project location and features should be provided. Include any reports or other supporting information available. The project must include a minimum of 15 taps with meters on each tap. I. ENTITY INFORMATION 1. Applicant Name of Entity 2. Type of Entity (Water District, Water & Sewer District, etc.) 3. Year of Formation 4. Physical Address (Street Address) 5. City 6. County 7. State 8. Zip Code 9. Phone 10. Mailing Address (If Different From Above) APPLICATION RURAL DOMESTIC WATER SYSTEMS PAGE 1 OF 6

2 11. Primary Contact Person (Type or Print Name) 12. Phone Best Time(s) to Reach Contact Person 15. Authorized Official (Type or Print Name) 16. Signature of Authorized Official 17. Date Before applying for project funding, the Wyoming Water Development Commission strongly recommends completion of a Public Water System Survey or Irrigation System Survey available through the link on the website located here: Has the application entity completed this survey? Yes No If the application was prepared by someone other than the contact person, please provide the following: 19. Name 20. Affiliation 21. Phone 22. ENTITY STATUS 23. Does an entity of local government exist? A. If an entity of local government exists, provide the following: (1) Type of Entity (Water District, Water & Sewer District, Improvement & Service District, etc.): (2) Date of Formation: (3) Attach a copy of your bylaws and the document creating your entity. B. If no entity exists, provide the following: (1) Has district formation started? (2) Has a petition been submitted to the City Council or County Commission? (3) Has the district formation hearing been held? (4) Has the district formation election been held or scheduled? 24. Is the area made up a subdivision, subdivisions, or un-platted development? 25. Provide the date or dates that the subdivision or subdivisions were approved by the City or County: 26. Provide a list of lot owners in the proposed service area. Include number of lots owned by each land owner. Designate the number of lots presently owned by the developer of the subdivision(s). 27. Is the project supported by the City Council or County Commission which has jurisdiction over the project area? A. Provide any comments from City Council or County Commission: 28. Have the land owners been contacted regarding this application? 29. What is the percentage of land owners that support this application? 30. Provide any additional information you would like us to know about the entity/district. Attach additional information if needed: APPLICATION RURAL DOMESTIC WATER SYSTEMS PAGE 2 OF 6

3 II. PURPOSE AND NEED 1. Provide a brief statement describing the project for which funding is sought, and include the reasons the project is needed. Describe the current situation with the water supply that will be improved by the project. What is the factor that is presently limiting the system supply capacity (e.g., treatment, storage, transmission, etc.)? Attach additional information if needed: 2. Specify whether the purpose of this application to obtain a Level I Reconnaissance or a Level II Feasibility Study: 3. Is the applicant entity under any federal (EPA) mandates to improve the water system (e.g., administrative orders, violations, actions taken, etc.)? 4. Operating Criteria of the Wyoming Water Development Program advocates prioritization of projects that may serve more than one entity or purpose and those that provide water to a larger, more regional area. Is the applicant entity currently served by a regionalized water supply system? If so please specify. Or will the applicant entity consider regional solutions to the purpose and needs of its water supply system? 5. List any previous work (studies) completed by or for the entity: 6. Provide a brief description of the water system operations. Identify the public works director. Identify any system automation within the operations (e.g., SCADA) and existence of any hydraulic models of the system. Describe existing mapping (e.g., paper, map books, GIS). Attach additional information if needed: APPLICATION RURAL DOMESTIC WATER SYSTEMS PAGE 3 OF 6

4 III. PERTINENT INFORMATION The intention of this section is to gather information on your existing water supply facilities. Answer all questions as completely and accurately as possible. Do not leave any questions blank. If questions are not applicable to your system, respond, N/A. If an answer to a question is unknown, respond, Unknown. If you need help, please call the Water Development Office at Existing Water Supply System A. EPA Public Water System (PWS) Identification Number: B. Groundwater (1) Number of Wells: (2) Primary Supply Aquifer(s) or Formation(s): (3) Total Average Production Yield of All Wells (GPM): C. Surface Water (1) Source Name(s): (2) Type of Diversion(s) (Headgate, Infiltration Gallery, Pumps, Etc.): (3) Total Average Diversion Yield (CFS or GPM): D. Springs (1) Name of Spring(s): (2) Total Average Production Yield of All Springs (GPM): E. Water Rights (1) For the water source supply (or supplies) described above, does the applicant entity possess valid and/or adjudicated water rights? F. Transmission Pipeline (1) Maximum Capacity of the Transmission Pipeline(s) (Gallons per Day): (2) Increased Capacity Needed (If Known) (Gallons per Day): (3) Approximate Distance from Source(s) to Distribution System: (4) Transmission Pipe Diameter(s): (5) Type of Transmission Pipe Material(s): (6) Age of Transmission Pipeline(s): (7) Condition of Transmission Pipeline(s): (8) Does the applicant possess clear title to transmission corridor easements? G. Water Storage (1) Raw (Volume and Tank Description): (2) Treated (Volume and Tank Description): H. Treatment (1) Specify Water Treatment (None, Chlorination, Filtration, Etc.): 2. Existing Water Distribution System A. Is the water use metered? B. Are the billings based on meter readings? APPLICATION RURAL DOMESTIC WATER SYSTEMS PAGE 4 OF 6

5 C. Identify unmetered usage (e.g., irrigation of parks, cemeteries, fire protection, etc.): D. Average Day Demand Water Usage (Gallons per Capita per Day): E. Maximum Day Demand Water Usage (Gallons per Capita per Day): F. Peak Hourly Demand Water Usage (Gallons per Capita per Day): G. Distribution Pipe Diameter(s): H. Type of Distribution Pipe Material(s): I. Age of Distribution Pipeline(s): J. Condition of Distribution Pipeline(s): K. Estimated System Water Losses (Percentage): L. Describe any fire flow protection that the system provides: M. What water conservation measures are employed? N. Does anyone in the service area haul water? O. Is there an independent raw water irrigation system? (1) Raw Water System Capacity (Gallons per Day): (2) Average Annual Raw Water Usage (Gallons per Year): 3. Demographic Information and Existing Water Service Area A. Population Being Served: B. Does the applicant have a comprehensive planning boundary? (1) If so, what is the estimated additional population that may be served in the future? C. How many taps are served within the district boundary? D. How many taps are served outside the district boundary? E. Identify names of other water systems served: F. Identify any existing planning reports (municipal or county) that address growth management in the project area. Provide titles and how copies of the reports could be obtained: 4. Financial Information A. Rates (1) Tap Fee(s) Residential: (2) Tap Fee(s) Commercial: (3) Average Residential Monthly Water Bill and Corresponding Gallons Used: APPLICATION RURAL DOMESTIC WATER SYSTEMS PAGE 5 OF 6

6 (4) Water Rates (Provide rates for all tiers and categories of use. Attach additional pages if needed.): (5) Identify any local conditions that affect the water rates (e.g., flow-through for frost prevention, etc.): B. Financial Statement (of Water Utility) (1) Revenues a. Annual Revenues Generated from Water Sales: b. Annual Revenues from Tap Fees: c. Annual Revenues from Other Sources: d. Total Annual Revenues: (2) Expenditures (3) Other a. Annual Budget for Operation and Maintenance Expenses: b. Annual Payments for Debt Retirement: c. Annual Payments to a Repair and Replacement Fund: d. Annual Payments to an Emergency Fund: e. Annual Payments for Other Purposes: f. Total Annual Payments: a. Balance in Repair and Replacement Fund: b. Balance in Emergency Fund: c. Annual Cost of Water Quality Testing: (4) Is the operation of the water system self-supporting in terms of revenues offsetting costs for operation, maintenance, debt retirement, replacement funds, emergency funds, etc.? a. If not, how is the difference subsidized? APPLICATION RURAL DOMESTIC WATER SYSTEMS PAGE 6 OF 6